Peer-reviewed article

Associations between undernutrition and malaria infection: a case-control study from Rwanda.

Uwimana A, Alexiou H, Mutoni JD, Robert A, Rujeni N et al. · 14 Oct 2025

Abstract

Background Undernutrition and malaria remain major global public health challenges. The relationship between nutritional status and malaria infection is complex. Better understanding of their association is needed to improve prevention and control of these health conditions. Undernutrition can be assessed by evaluating nutrient intake (macronutrient and micronutrient intake) measured through Food Frequency Questionnaire or by using indicators for chronic undernutrition, including the stunting parameter defined by the World Health Organization as child being too short for age. This study aims to investigate associations between inadequate nutrient intake or indicators for undernutrition and malaria infection. Methods The analysis compares malaria cases diagnosed by a positive blood smear against controls composed of other malaria free people living in the same households with the cases (same household grouping). Data collection was conducted between November 2021 and December 2023 across 9 endemic districts located in all four provinces and Kigali City. Regression models were developed to investigate the association between undernutrition (i.e. inadequate nutrient intake or stunting) and malaria infection. Results Despite numerous nutrition interventions aimed at reducing the burden of undernutrition, the dietary patterns observed in this study remain predominantly imbalanced. The food composition was predominantly made up of starchy staples, accounting for 56.7% of total energy intake. Such foods are typically rich in macronutrients but low in essential micronutrients. The findings revealed a high prevalence of micronutrient deficiency risk, with a reported risk of vitamin A, B2, B12, calcium, zinc, and selenium deficiency between 50 and 80% in the studied population. Regarding stunting, even if the percentage of severe chronic stunting was higher in malaria cases (17%) compared to controls (10,6%), the association between stunting and malaria infection was not statistically significant. After adjusting for covariates, risk of vitamin E deficiency and risk of iron deficiency were positively associated with malaria (aOR = 7.46; 95% CI 4.43-12.58; p < 0.001 and aOR = 1.80; 95% CI 1.11-2.93; p = 0.017, respectively). Conversely, age, sex, and risk of selenium deficiency intake were inversely associated with malaria. Increasing age (aOR = 0.58; 95% CI 0.36-0.95; p < 0.04), female sex (aOR = 0.67; 95% CI 0.46-0.97; p < 0.001), and selenium deficiency (aOR = 0.62; 95% CI 0.43-0.91; p = 0.013) were all linked to lower odds of malaria infection. Conclusions These findings highlight the critical role of nutrient imbalances in influencing malaria infections. Therefore tackling these preventable deficiencies is required through targeted strategies as guided by UNICEF conceptual framework 2020-2030. For instance, improving dietary diversity, regularly monitoring nutritional status, and establishing a comprehensive national food composition database could support such strategies. These approaches will support effective nutrition policies and interventions.